Basic Information
| Provider Information | |||||||||
| NPI: | 1053549956 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOSMA | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | SUE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3707 NEW VISION DR | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468451702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604694763 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3707 NEW VISION DR | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468451702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604694763 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2009 | ||||||||
| LastUpdateDate: | 01/27/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 4301095084 | MI | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 390200000X | 4301095084 | MI | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.